Ryan White Research Articles

A Pilot Outreach HIV Testing Project Among Homeless Adults.

Background: The Memphis metropolitan statistical area (MSA) represents a Deep Southern U.S. city disproportionally affected by the ongoing transmission of new HIV cases as well as those diagnosed in late-stage disease. This region is a subset of nine states, including Memphis, Tennessee (project site), driving the epidemic in the United States. Memphis ranks 4th among all U.S. MSAs for new HIV infections and has been identified in the CDC's Ending the HIV Epidemic Initiative as a high HIV burden geographic focus area. The Memphis Ryan White Part A Program conducted a pilot project among adults seeking services in Memphis emergency and transitional housing shelters to offer on-site, rapid HIV testing. In this paper we describe the results from this aforementioned pilot study, including the rate of HIV test acceptance and potential factors associated with a history of HIV testing in Memphis.Methods: Community-engaged research approaches were employed via a partnership between the local health department, a federally qualified faith-based health center, and an academic university. An interviewer-administered survey to measure potential factors associated with HIV testing history and voluntary HIV testing services were offered to adults living in transitional housing establishments. Bivariate chi-square analyses were performed to determine the association between predisposing, enabling, and need variables with HIV testing history in the past 12 months.Results: Survey respondents (n = 109) were mostly cisgender male (n = 96; 88.1%), African American (n = 79; 72.5%) and reported engaging in condomless sex in the past 12 months (n = 55; 50.5%). Acceptability and uptake of HIV testing was high (n = 97; 89.0%).Conclusions: Implementing rapid HIV testing programs outside of traditional health care settings is a strategy that can be used to engage high-risk individuals and those unaware of their HIV status to get tested. To our knowledge, this study represents the first that documents HIV testing acceptance rates offered outside of traditional health care settings for homeless and transitionally housed adults in a Deep Southern state.

Factors Associated with Viral Suppression Among Racial/Ethnic Minority Women in the Miami-Dade County Ryan White Program, 2017.

The study's objective was to identify factors associated with differences in the rate of viral suppression among minority women with HIV/AIDS in care in the Miami-Dade County Ryan White Program (RWP). A retrospective cohort study was conducted using social characteristics and laboratory data of minority women enrolled in the Miami-Dade County RWP in 2017. Viral suppression was defined as <200 copies/mL using the last viral load test of 2017. Multilevel logistic regression models were used to estimate adjusted odds ratio (aOR) and 95% confidence intervals (CIs). Of the 1,550 racial/ethnic minority women in the study population, 43.1% were African American, 31.3% were Hispanic, and 25.6% were Haitian. The proportion of women virally suppressed was lower among African Americans (80.8%) than among Hispanics (86.4%) and Haitians (85.1%). Viral suppression rates were significantly lower among women aged 18-34 years (aOR: 0.41, CI: 0.27-0.64) and 35-49 years (0.63, 0.45-0.90) vs. ≥50 years, born in the United States (0.48, 0.30-0.78), having a household income of <100% the federal poverty level (0.54, 0.30-0.95), previously diagnosed with AIDS (0.60, 0.44-0.81), reporting problematic drug use (0.23, 0.08-0.69), and living in a residentially unstable neighborhood (0.77, 0.64-0.93). Race/ethnicity was not associated with viral suppression after adjusting for other factors. Factors associated with lack of viral suppression were similar among minority racial/ethnic groups. Interventions at the individual level focusing on young, U.S. born individuals, and those who report drug use, and at the neighborhood level for those living in residentially unstable neighborhoods are needed to improve viral suppression outcomes.

Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City.

Prior research has found evidence of gender disparities in U.S. HIV healthcare access and outcomes. In order to assess potential disparities in our client population, we compared demographics, service needs, service utilization, and HIV care continuum outcomes between transgender women, cisgender women, and cisgender men receiving New York City (NYC) Ryan White Part A (RWPA) services. The analysis included HIV-positive clients with an intake assessment between January 2016 and December 2017 in an NYC RWPA services program. We examined four service need areas: food and nutrition, harm reduction, mental health, and housing. Among clients with the documented need, we ascertained whether they received RWPA services targeting that need. To compare HIV outcomes between groups, we applied five metrics: engagement in care, consistent engagement in care, antiretroviral therapy (ART) use, point-in-time viral suppression, and durable viral suppression. All four service needs were more prevalent among transgender women (N = 455) than among cisgender clients. Except in the area of food and nutrition services, timely (12-month) receipt of RWPA services to meet a specific assessed need was not significantly more or less common in any one of the three client groups examined. Compared to cisgender women and cisgender men, a lower proportion of transgender women were durably virally suppressed (39% versus 52% or 50%, respectively, p-value < 0.001). Compared with cisgender women and cisgender men, transgender women more often presented with basic (food/housing) and behavioral-health service needs. In all three groups (with no consistent between-group differences), assessed needs were not typically met with the directly corresponding RWPA service category. Targeting those needs with RWPA outreach and services may support the National HIV/AIDS Strategy 2020 goal of reducing health disparities, and specifically the objective of increasing (to ≥90%) the percentage of transgender women in HIV medical care who are virally suppressed.

Development and Validation of Vulnerable and Enabling Indices for HIV Viral Suppression among People with HIV Enrolled in the Ryan White Program.

Background: Numerous factors impact HIV care, often requiring consideration of indices to prevent collinearity when using statistical modeling. Using the Behavioral Model for Vulnerable Populations, we developed vulnerable and enabling indices for people living with HIV (PLWH). Methods: We used Ryan White Program (RWP) data and principal component analysis to develop general and gender- and racial/ethnic-specific indices. We assessed internal reliability (Cronbach’s alpha), convergent validity (correlation coefficient), and predictive utility (logistic regression) with non-viral suppression. Results: Three general factors accounting for 79.2% of indicators’ variability surfaced: mental health, drug use, and socioeconomic status (Cronbach’s alpha 0.68). Among the overall RWP population, indices showed convergent validity and predictive utility. Using gender- or racial/ethnic-specific indices did not improve psychometric performance. Discussion: General mental health, drug use, and socioeconomic indices using administrative data showed acceptable reliability, validity, and utility for non-viral suppression in an overall PLWH population and in gender- and racial/ethnic-stratified populations. These general indices may be used with similar validity and utility across gender and racial/ethnic diverse populations.

Time between diagnosis and achievement of virologic suppression in people living with HIV.

Data support the individual and public health advantages of shortened time intervals between HIV diagnosis, initiation of antiretroviral therapy (ART), and virologic suppression. The time from HIV diagnosis to linkage to care, initiation of ART, and virologic suppression was evaluated in newly diagnosed, ART-naive individuals after structured programmatic changes were implemented to reduce time to virologic suppression (TVS). The retrospective cohort included newly diagnosed, ART-naive adult patients receiving care in a Midwestern Ryan White Clinic. Study periods were between January 1, 2015, and December 31, 2015 (delayed treatment group) and January 1, 2017, and December 31, 2017 (rapid treatment group). Changes during the intervention time period were related to access to care and ART. The primary outcome of time from HIV diagnosis to virologic suppression was compared between the groups. Secondary outcomes included the time from diagnosis to linkage to care and the time to initiation of ART. Twenty-four and 35 individuals were included in the control and intervention groups, respectively. Median (interquartile range) time from diagnosis to viral suppression was 137 (77-318) days in the delayed treatment group vs 76.5 (51-151) days in the rapid treatment group (P = 0.021). Time from diagnosis to first clinic visit remained similar (median of 13.5 vs 15 days, P = 0.859), while time from first clinic visit to initiation of ART decreased significantly (median of 15 vs 0 days, P < 0.001). Time from first clinic visit to ART initiation was significantly shortened in this intervention and was the driving force to decreasing TVS. Additional research into barriers impacting time from diagnosis to linkage to care are needed to further shorten TVS.

Strengths and Challenges of Implementing a Learning Collaborative in the Ryan White HIV/AIDS Program.

Learning collaboratives (LCs) are a popular tool for supporting collaboration and shared learning among health programs. Many variations of LCs have been reported in the literature. However, descriptions of key LC components and implementation lack standardization, making it hard to compare and contrast different LC approaches. To advance the field's understanding of how primary elements of LCs are implemented, we describe the implementation of an LC in the Ryan White HIV/AIDS Program using a recently established taxonomy of four primary elements of LCs-innovation, social systems, communication, and time. Additionally, we explain the strengths and challenges we encountered with regard to each of these elements when implementing this LC. We then offer recommendations to others on how to leverage LC facilitators and mitigate challenges in future projects. This information can guide other programs to replicate beneficial practices and avoid pitfalls in future LC projects.

Changes in Body Mass Index Associated with Antiretroviral Regimen Switch Among Treatment-Experienced, Virologically Suppressed People Living with HIV in the United States

With obesity on the rise among people living with HIV (PLWH), there is growing concern that weight gain may result as an undesired effect of antiretroviral therapy (ART). This analysis sought to assess the association between ART regimens and changes in body mass index (BMI) among ART-experienced, virologically suppressed PLWH. ART-experienced, virologically suppressed PLWH ≥18 years of age in the Observational Pharmacoepidemiology Research and Analysis (OPERA) cohort were included for analysis if prescribed a new regimen containing one of the following core agents: dolutegravir (DTG), elvitegravir/cobicistat (EVG/c), raltegravir (RAL), rilpivirine (RPV), or boosted darunavir (bDRV), for the first time between August 1, 2013 and December 31, 2017. Multivariable linear regression was used to assess the association between regimen and mean changes in BMI at 6, 12, and 24 months after switch. In unadjusted analyses, BMI increases ranged from 0.30 kg/m2 (bDRV) to 0.83 kg/m2 (RPV) at 24 months following switch, but gains were observed with every regimen. In adjusted analyses, compared to DTG, only bDRV was associated with a smaller increase in BMI at all time points, while EVG/c and RAL were associated with smaller increases in BMI at 6 months only. Overall, results were consistent in analyses stratified by baseline BMI category. BMI increases were relatively small but followed an upward trend over time in this cohort of treatment-experienced, suppressed PLWH. Gains were attenuated with a longer period of follow-up. BMI gains did not differ by regimens, except for bDRV regimens, which were consistently associated with smaller BMI increases than DTG.

Brief Report: Hospitalization Rates Among Persons With HIV Who Gained Medicaid or Private Insurance After the Affordable Care Act in 2014.

It is unknown whether gaining inpatient health care coverage had an effect on hospitalization rates among persons with HIV (PWH) after implementation of the Affordable Care Act in 2014. Hospitalization data from 2015 were obtained for 1634 adults receiving longitudinal HIV care at 3 US HIV clinics within the HIV Research Network. All patients were engaged in care and previously uninsured and supported by the Ryan White HIV/AIDS Program in 2013. We evaluated whether PWH who transitioned to either Medicaid or private insurance in 2014 tended to have a change in hospitalization rate compared with PWH who remained uncovered and Ryan White HIV/AIDS Program supported. Analyses were performed by negative binomial regression with robust standard errors, adjusting for gender, race/ethnicity, age, HIV risk factor, CD4 count, viral load, clinic site, and 2013 hospitalization rate. Among PWH without inpatient health care coverage in 2013, transitioning to Medicaid [adjusted incidence rate ratio 1.26, (0.71, 2.23)] or to private insurance [0.48 (0.18, 1.28)] in 2014 was not associated with 2015 hospitalization rates, after accounting for demographics, HIV characteristics, and prior hospitalization rates. The factors significantly associated with higher hospitalization rates include age 55-64, CD4 <200 cells/µL, viral load >400 copies/mL, and 2013 hospitalization rate. Acquiring inpatient coverage was not associated with a change in hospitalization rates. These results provide some evidence to allay the concern that acquiring inpatient coverage would lead to increased inpatient utilization.

A pandemic anniversary: 40 years of HIV/AIDS

A pandemic anniversary: 40 years of HIV/AIDS

\u201cPart of getting to where we are is because we have been open to change\u201d integrating community health workers on care teams at ten Ryan White HIV/AIDS program recipient sites

BackgroundCommunity Health Workers (CHWs) have long been integrated in the delivery of HIV care in middle- and low-income countries. However, less is known about CHW integration into HIV care teams in the United States (US). To date, US-based CHW integration studies have studies explored integration in the context of primary care and patient-centered medical homes.There is a need for research related to strategies that promote the successful integration of CHWs into HIV care delivery systems. In 2016, the Health Resources and Services Administration HIV/AIDS Bureau launched a three-year initiative to provide training, technical assistance and evaluation for Ryan White HIV/AIDS Program (RWHAP) recipient sites to integrate CHWs into their multidisciplinary care teams, and in turn strengthen their capacity to reach communities of color and reduce HIV inequities.MethodsTen RWHAP sites were selected from across eight states. The multi-site program evaluation included a process evaluation guided by RE-AIM to understand how the organizations integrated CHWs into their care teams. Site team members participated in group interviews to walk-the-process during early implementation and following the program period. Directed content analysis was employed to examine program implementation. Codes developed using implementation strategies outlined in the Expert Recommendations for Implementing Change project were applied to group interviews (n = 20).FindingsImplementation strategies most frequently described by sites were associated with organizational-level adaptations in order to integrate the CHW into the HIV care team. These included revising, defining, and differentiating professional roles and changing organizational policies. Strategies used for implementation, such as network weaving, supervision, and promoting adaptability, were second most commonly cited strategies, followed by training and Technical Assistance strategies.ConclusionsWrapped up in the implementation experience of the sites there were some underlying issues that pose challenges for healthcare organizations. Organizational policies and the ability to adapt proved significant in facilitating CHW program implementation. The integration of the CHWs in the delivery of HIV care requires clearly distinguishing their role from the roles of other members of the healthcare delivery team.

Reducing Disparities: A Virtual Quality Improvement Collaborative Resulted in Better Health Outcomes for 4 Target Populations Disproportionately Affected by HIV.

Although viral suppression rates have recently increased among people with HIV, specific populations still experience disparities in health outcomes, a priority in the national response to end the HIV epidemic. The end+disparities ECHO Collaborative, a quality improvement initiative among HIV providers in the United States from June 2018 to December 2019, created virtual communities of practice to measurably increase viral suppression rates in populations disproportionately affected by HIV: men who have sex with men of color, Black/African American and Latina women, youth aged 13 to 24 years, and transgender people. Participating Ryan White HIV/AIDS Program-funded providers prioritized their improvement efforts to focus on one target population and joined virtual affinity sessions with other providers focused on that population for guidance by subject matter experts and exchanges with peer providers. During 9 submission cycles, providers reported their viral suppression data for the preceding 12 months. The principal outcome measures were changes in viral suppression rates among 4 target populations and changes in viral suppression gaps compared with the rest of HIV-infected patients served by the same agency. A total of 90 providers were included in the data analyses with an average of 110 775 reported patients, out of which 19 442 represented the targeted populations. The average viral suppression rates for agency-selected populations increased from 79.2% to 82.3% (a 3.9% increase), while the remaining caseload increased at a lower rate from 84.9% to 86.1% (a 1.4% increase). The viral suppression gap was reduced from 5.7% to 3.8%, a 33.5% reduction. Improvements were found across all target populations. The collaborative demonstrated improved health outcomes and reductions in HIV-related health disparities, moving toward ending the HIV epidemic. The model of utilizing low-cost videoconferencing technologies to create virtual communities of learning is well suited to mitigate other disease-related disparities, nationally and abroad.

An Implementation Strategy to Expand Mobile Health Use in HIV Care Settings: Rapid Evaluation Study Using the Consolidated Framework for Implementation Research.

BackgroundMobile health (mHealth) apps can provide support to people living with a chronic disease by offering resources for communication, self-management, and social support. PositiveLinks (PL) is a clinic-deployed mHealth app designed to improve the health of people with HIV. In a pilot study, PL users experienced considerable improvements in care engagement and viral load suppression. To promote its expansion to other HIV clinics, we developed an implementation strategy consisting of training resources and on-demand program support.ObjectiveThe objective of our study was to conduct an interim analysis of the barriers and facilitators to PL implementation at early adopting sites to guide optimization of our implementation strategy.MethodsSemistructured interviews with stakeholders at PL expansion sites were conducted. Analysis of interviews identified facilitators and barriers that were mapped to 22 constructs of the Consolidated Framework for Implementation Research (CFIR). The purpose of the analysis was to identify the facilitators and barriers to PL implementation in order to adapt the PL implementation strategy. Four Ryan White HIV clinics were included. Interviews were conducted with one health care provider, two clinic managers, and five individuals who coordinated site PL activities.ResultsTen common facilitators and eight common barriers were identified. Facilitators to PL implementation included PL’s fit with patient and clinic needs, PL training resources, and sites’ early engagement with their information technology personnel. Most barriers were specific to mHealth, including access to Wi-Fi networks, maintaining patient smartphone access, patient privacy concerns, and lack of clarity on how to obtain approvals for mHealth use.ConclusionsThe CFIR is a useful framework for evaluating mHealth interventions. Although PL training resources were viewed favorably, we identified important barriers to PL implementation in a sample of Ryan White clinics. This enabled our team to expand guidance on identifying information technology stakeholders and procuring and managing mobile resources. Ongoing evaluation results continue to inform improvements to the PL implementation strategy, facilitating PL access for future expansion sites.

Health information technology interventions and engagement in HIV care and achievement of viral suppression in publicly funded settings in the US: A cost-effectiveness analysis.

BackgroundThe US National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined cost-effectiveness from the health system perspective of 6 health information technology (HIT) interventions implemented during 2008 to 2012 in a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program demonstration project.Methods/findingsHIT interventions were implemented at 6 sites: Bronx, New York; Durham, North Carolina; Long Beach, California; New Orleans, Louisiana; New York, New York (2 sites); and Paterson, New Jersey. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records (EHRs) to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. We employed standard microcosting techniques to estimate costs (in 2018 US dollars) associated with intervention implementation. Data from a sample of electronic patient records from each demonstration site were analyzed to compare prescription of antiretroviral therapy (ART), CD4 cell counts, and suppression of viral load, before and after implementation of interventions. Markov models were used to estimate additional healthcare costs and quality-adjusted life-years saved as a result of each intervention. Overall, demonstration site interventions cost $3,913,313 (range = $287,682 to $998,201) among 3,110 individuals (range = 258 to 1,181) over 3 years. Changes in the proportion of patients prescribed ART ranged from a decrease from 87.0% to 72.7% at Site 4 to an increase from 74.6% to 94.2% at Site 6; changes in the proportion of patients with 0 to 200 CD4 cells/mm3 ranged from a decrease from 20.2% to 11.0% in Site 6 to an increase from 16.7% to 30.2% in Site 2; and changes in the proportion of patients with undetectable viral load ranged from a decrease from 84.6% to 46.0% in Site 1 to an increase from 67.0% to 69.9% in Site 5. Four of the 6 interventions—including use of HIV surveillance data to identify out-of-care individuals, use of electronic laboratory ordering and prescribing, and development of a patient portal—were not only cost-effective but also cost saving ($6.87 to $14.91 saved per dollar invested). In contrast, the 2 interventions that extended access to EHRs to support service providers were not effective and, therefore, not cost-effective. Most interventions remained either cost-saving or not cost-effective under all sensitivity analysis scenarios. The intervention that used HIV surveillance data to identify out-of-care individuals was no longer cost-saving when the effect of HIV on an individual’s health status was reduced and when the natural progression of HIV was increased. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess sites against themselves at baseline and not against standard of care during the same time period.ConclusionsThese results provide additional support for the use of HIT as a tool to enhance rapid and effective treatment of HIV to achieve sustained viral suppression. HIT has the potential to increase utilization of services, improve health outcomes, and reduce subsequent transmission of HIV.

Preparing Children for International Travel.

1. Hiba Chehab, MD, FAAP* 2. Philip R. Fischer, MD, FAAP†,‡ 3. John C. Christenson, MD, FAAP* 1. *Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 2. †Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 3. ‡Pediatrics Department, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates * Abbreviations: CDC : : Centers for Disease Control and Prevention DEET N : : N-diethyl-m-toluamide HACE : : high-altitude cerebral edema HAI : : high-altitude illness HAPE : : high-altitude pulmonary edema MenACWY : : meningococcal quadrivalent conjugate vaccine MMR : : measles-mumps-rubella PCR : : polymerase chain reaction TD : : traveler’s diarrhea 1. Pediatricians may be unfamiliar with agents that are most effective for antimalarial prophylaxis for a young infant traveler. 2. Pediatricians may not realize that measles-mumps-rubella and hepatitis A vaccines are recommended for infant travelers 6 months and older. After completing this article, readers should be able to: 1. Select the most appropriate antimalarial prophylaxis agent according to high-risk regions. 2. Use insect bite prevention strategies to prevent malaria, dengue, and other vector-borne diseases. 3. Recognize which vaccines are necessary for the young pediatric traveler. Traveling with a child can be emotionally and educationally rewarding but challenging as well. Children are traveling from North America and Europe to most parts of the world, including Sub-Saharan Africa, Asia, and Central and South America. The most common reasons to travel are for leisure and to visit friends and relatives. (1) Children also accompany their families for pilgrimages, study abroad experiences, and parental work. Older children and adolescents travel as part of educational tours and humanitarian mission trips. Similar to adults, children traveling to potentially high-risk regions of the world expose themselves to risks of acquiring malaria, dengue, and diarrheal diseases. These diseases, followed by dermatologic conditions such as cellulitis, bites, and cutaneous larva migrans, are among the most common problems observed in pediatric travelers. Travelers visiting friends and relatives are at a greater risk because most do not visit travel clinics for advice or immunizations. (2)(3) They also tend to visit more remote parts of high-risk countries and stay for longer durations. Although at-risk children may not visit a travel clinic, they may be seen by their primary care health provider. Pediatricians, through setting …

Predictors of chlamydia or gonorrhea among people with HIV in Miami-Dade County Ryan White Program in 2017

ABSTRACT The purpose of this study was to assess the prevalence of chlamydia or gonorrhea and factors associated with the diagnoses among people with HIV (PHIV) in the Ryan White Program Part A (RWP) in Miami-Dade County, Florida. We used 2017 calendar year data to identify factors associated with a chlamydia or gonorrhea diagnoses using logistic regression. About 50% of the 7110 PHIV who were ≥18 years old in active Ryan White care in 2017 reported being screened for chlamydia or gonorrhea. Of those screened, 2.3% reported diagnoses of chlamydia, gonorrhea or both. In the adjusted model, compared to PHIV ≥40 years-old, PHIV aged 18–24 and 25–39 years reported higher odds of diagnoses (adjusted odds ratio [aOR] 4.29; 95% confidence interval [CI]: 1.73–10.63 and aOR 4.58; 95% CI; 2.62–7.99 respectively). Those with multiple sexual partners in the last 12 months reported higher odds of diagnoses (aOR 1.67; (95% CI; 1.04–2.69)). Screening rates for chlamydia or gonorrhea are low, relative to CDC guidelines. Interventions are needed to increase rates of screening and targeted behavioral risk reduction techniques are highly recommended among those 18–39 years of age and those who have multiple sexual partners.

Cost-Effectiveness of HRSA's Ryan White HIV/AIDS Program?

With an annual budget of more than $2 billion, the Health Resources and Services Administration's Ryan White HIV/AIDS Program (RWHAP) is the third largest source of public funding for HIV care and treatment in the United States, yet little analysis has been done to quantify the long-term public health and economic impacts of the federal program. Using an agent-based, stochastic model, we estimated health care costs and outcomes over a 50-year period in the presence of the RWHAP relative to those expected to prevail if the comprehensive and integrated system of medical and support services funded by the RWHAP were not available. We made a conservative assumption that, in the absence of the RWHAP, only uninsured clients would lose access to these medical and support services. The model predicts that the proportion of people with HIV who are virally suppressed would be 25.2 percentage points higher in the presence of the RWHAP (82.6 percent versus 57.4 percent without the RWHAP). The number of new HIV infections would be 18 percent (190,197) lower, the number of deaths among people with HIV would be 31 percent (267,886) lower, the number of quality-adjusted life years would be 2.7 percent (5.6 million) higher, and the cumulative health care costs would be 25 percent ($165 billion) higher in the presence of the RWHAP relative to the counterfactual. Based on these results, the RWHAP has an incremental cost-effectiveness ratio of $29,573 per quality-adjusted life year gained compared with the non-RWHAP scenario. Sensitivity analysis indicates that the probability of transmitting HIV via male-to-male sexual contact and the cost of antiretroviral medications have the largest effect on the cost-effectiveness of the program. The RWHAP would be considered very cost-effective when using standard guidelines of less than the per capita gross domestic product of the United States. The results suggest that the RWHAP plays a critical and cost-effective role in the United States' public health response to the HIV epidemic.

Latent Class Analysis of Syndemic Factors Associated with Sustained Viral Suppression among Ryan White HIV/AIDS Program Clients in Miami, 2017

The study's objective was to identify the association between sustained viral suppression (all viral load tests < 200 copies/ml per year) and patterns of co-occurring risk factors including, mental health, substance use, sexual risk behavior, and adverse social conditions for people with HIV (PWH). Latent class analysis followed by multivariable logistic regression was conducted for 6554 PWH in the Miami-Dade County Ryan White Program during 2017, and a five-class model was selected. Compared to Class 1 (no risk factors), the odds of achieving sustained viral suppression was significantly lower for Class 2 (mental health) (aOR: 0.67; 95% CI 0.54-0.83), Class 3 (substance use and multiple sexual partners) (0.60; 0.47-0.76), Class 4 (substance use, multiple sexual partners, and domestic violence) (0.71; 0.55-0.93), and Class 5 (mental health, substance use, multiple sexual partners, domestic violence, and homelessness) (0.26; 0.19-0.35). Findings indicate the need for targeted interventions that address these syndemic factors.

Evidence and Lessons on the Health Impacts of Public Health Funding from the Fight Against Hiv/Aids

HIV/AIDS has been one of the largest public health crises in recent history, and the U.S. federal government has spent hundreds of billions of dollars fighting the disease. This study examines the impact of federal funding allocated to U.S. cities through the Ryan White CARE Act, which is the largest program for combating HIV/AIDS in the United States. The empirical approach identifies the impact of the funding by studying funding variation that comes from Ryan White policy features that resulted in large funding differences among cities that were originally on parallel HIV/AIDS trajectories and finds that Ryan White's city-level funding has improved HIV/AIDS outcomes in the cities receiving the funds. The estimates indicate that one HIV/AIDS death has been avoided for every $314,000 allocated through the program and that the program has saved approximately 60,000 lives through 2018. The estimates also indicate that funding differences across cities have contributed to the uneven progress in combating HIV/AIDS across the United States. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Associations of HCV Knowledge and Medical Mistrust with Being Screened for HCV and Offered HCV Treatment among People with HIV.

An estimated one-fourth of people with HIV in the U.S. are coinfected with hepatitis C virus (HCV). We examined patient-related correlates of HCV screening and treatment in a convenience sample of 1,853 HIV-positive adults in Connecticut, Louisiana, New York, North Carolina, Pennsylvania, and Texas. Overall, 85.1% reported being screened for HCV, and 30.8% reported ever being offered treatment. In multivariate logistic regressions, greater HCV knowledge, lower HCV-related medical mistrust, older age, and prior substance use treatment were associated with higher screening and treatment likelihoods. For screening, Ryan White HIV/AIDS Program eligibility, having a high school education or less, and identifying as "other" race/ethnicity were additionally significant. Mistrust, which has arisen as a response to centuries of systemic racism, mediated the association between combined Black/Latino race/ethnicity and lower screening likelihood. We recommend patient-level (e.g., peer navigation) and provider interventions to integrate HCV screening and treatment into HIV care.

Provider Perceptions of Barriers to HIV Care Among Women with HIV in Miami-Dade County, Florida, and Possible Solutions: A Qualitative Study

In Miami-Dade County, women with HIV (WWH) enrolled in Ryan White Program (RWP) services belong to groups that have historically faced structural barriers to care. To examine provider perceptions of WWH's barriers to care and elicit possible solutions, we conducted semi-structured interviews (n = 20) with medical case managers and human immunodeficiency virus (HIV) healthcare providers from medical case management sites serving WWH enrolled in the Miami-Dade RWP. Verbatim transcripts were analyzed thematically by two coders through an iterative process; disagreements were resolved through consensus. Barriers included lack of disclosure and stigma, additional psychosocial barriers to care, structural and logistical barriers, and negative interactions with health care providers. Participant suggestions to address these barriers included strategies that support women and foster individualized services that are responsive to their lived experiences and needs. Other solutions, such as those related to transportation, housing, and general funding for the RWP, will require advocacy and policy change.